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Assessing eyelid swelling that represents active inflammation is sometimes difficult for several reasons. Periorbital fullness varies enormously between normal subjects due to age, general body mass, and the integrity of the anterior orbital septum (AOS). As the AOS weakens with age, a degree of orbital fat prolapse is common. Unfortunately, recent premorbid photographs are rarely available to confirm change. Additionally, this anterior displacement of fat and also the lacrimal gland may have been exacerbated by GO regardless of whether it is currently active. Hence assessing what represents active swelling will rely on ascertaining probable recent change and noting signs of either subcutaneous fluid or rather tense skin, usually in the context of other signs of activity as discussed below (Fig. 5). Note that subcutaneous fluid bags, known as festoons, occasionally persist for years, implying that their resolution does not mirror the resolution in activity.

Fig. 5. Assessment of eyelid swelling. a Moderate active swelling. There is definite subcutaneous fluid (black arrows) or skin thickening (white arrows), but swelling is not tense. This is more than just fat prolapse as the fat pads are not seen distinctly. b Severe active swelling. There is tense subcutaneous fluid (black arrows) or thickened skin (white arrows). Note that in the upper eyelid, moderate swelling is distinguished from severe swelling by asking the patient to look down slightly: the central part of the skin fold remains a fold and is not rounded in moderate swelling (c), whereas it remains rounded in severe swelling (d). In the lower eyelid with moderate swelling, the fluid does not fold the skin (e), whereas it does in severe swelling (f).